RFR 232727 Application form Category 2.doc

The Commonwealth of Massachusetts

Executive Office of Health and Human Services

Department of Public Health Purchase of Service Office 250 Washington Street, Boston, MA 02108-4619

APPLICATION RESPONSE FORM

Category 2 – Training to be Developed or Modified

RFR TITLE Specialized Training Services for Small (<$50,000) Projects RFR# 232727

Organization Name: [ ] www: [ ] Address:

City: [ ] State: [ ] Zip: [ ] Contact Person: First Name: [ ] Last Name: [ ]

Title: [ ] Telephone: ( ) -

FAX: ( ) -

E-Mail: [ ] Commonwealth Vendor Customer Code (VCC)* (if available): [ ] Address Code: [ ] *for contract execution

PROFESSIONAL EXPERTISE

List your areas of professional expertise in specialized public health, healthcare or safety training services (maximum of one paragraph).

Enter text here

PROFESSIONAL EXPERIENCE

Describe your experience providing specialized health, healthcare or safety training services. Include staff qualifications, with relevant licenses and certifications.

Enter text here

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Résumé(s) or CV(s) detailing the experience of key specialized health, healthcare or safety training staff attached.

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Copies of relevant staff licenses and certifications attached.

CATEGORY 2: TRAINING WITH CONTENT TO BE DEVELOPED OR MODIFIED

List maximum hourly rate for staff members who are developing or modifying or delivering a training:

Maximum Hourly Rate*: [$ ]

*Set for the term of the contract.

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Staff rate sheets may be attached.

This hourly rate is established for the term of the master agreement contract as the maximum rate of staff that may work on a project.

An engagement form must be completed for specific departmental projects that will detail a budget and scope of work using the Fixed-Price Engagement form. Representatives from the department will contact vendors on this contract as needed for instruction services with content to be developed or modified. See section 3.2.2 of the RFR for more information about Instruction with Content To Be Developed or Modified.

Applicant affirms by signing below, that all individuals that work on a project for DPH will be appropriately licensed and/or Board certified. A copy of license(s) and/or certificate(s) may be required at the time of engagement.

Authorized Signatory:

First Name: [ ] Last Name: [ ] Title: [ ]

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By clicking the check box, the submitter attests that s/he is an agent of the Bidder with authority to sign on the Bidder’s behalf.

REQUIRED APPLICATION DOCUMENTS

The Application Response Form

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Résumé(s) or CV(s) detailing the experience of key specialized health, healthcare or safety training staff attached.

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Copies of relevant staff licenses and certifications attached.

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Staff rates attached. (If applicable)

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Business Reference Form

Additional forms listed on the COMMBUYS Attachment Section for this RFR must be completed and submitted with your response in accordance with the instructions.

APPLICATION INSTRUCTIONS

1. Upload in COMMBUYS the Application Response Form with the required attachments

2. Submit your electronic quote in COMMBUYS. (Vendors must be registered in COMMBUYS to submit quotes)